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RESPIRATORY PROTECTION HS1$'Q.Z1 IVED <br />Employee Sign -Off Sheet AUG 10 2005 <br />Respiratory Protection OFFICE OF EMERGENCY SETy <br />RVICES <br />Name: Iwi z Date: - � 5 <br />C <br />Last, First MI <br />A. Employee has received instruction on proper care of respirator. <br />B. Employee received detail review on donning of respirator. <br />C. Employee has received instruction on cleaning and storage of <br />Respirator. <br />D. Employee has demonstrated positive/negative respirator test. <br />E. Employee has completed respiratory questionaire and examination <br />F. Employee has been fit tested (See form FM130.20) <br />acknowledge receiving the training described in this document and I commit to abiding <br />by the safety rules and regulations presented to me. <br />1 <br />2 December 2003 7 Sierra Chemical Co. <br />